Alameda County
Department of Environmental Health
Office of Solid/Medical Waste Management
1131 Harbor Bay Parkway ● Alameda, CA 94502
Phone: (510) 567-6790 ● Fax: (510) 337-9234
www.acgov.org/aceh
_____________________________________________________________________________________________________________
MEDICAL WASTE GENERATOR REGISTRATION APPLICATION FORM
WHO IS REQUIRED TO REGISTER?
Each Large Quantity Generator (LQG) shall register with the enforcement agency pursuant to the California Health and Safety Code,
Division 104, Part 14, California Medical Waste Management Act ([H&SC § 117950(a)]. The Large Quantity Generator (LQG) registration is
valid for one year [H&SC § 117970(b)]. Facilities that generate equal to or more than 200 pounds in any month of the year of
medical/biohazardous waste are categorized as Large Quantity Generators (LQG).
A medical waste Common Storage Facility that collects the accumulated waste of more than one medical waste generator shall be
registered with the enforcement agency (H&SC § 117908).
Each Small Quantity Generator (SQG) using on-site treatment such as steam sterilization shall register with the enforcement agency
[H&SC § 117925(a)].
To register, complete this form and submit to Alameda County Department of Environmental Health, Office of Solid/Medical Waste
Management.
Type of Application:
 New Registration/Permit
 Renewal
 Change of Ownership
I. FACILITY INFORMATION
Facility Name:
Address:
City/Zip
Mailing Address:
City/Zip
Contact Person:
Telephone:
Email Address:
Fax:
II. GENERATOR CATEGORIES REQUIRING REGISTRATION
Application Type: Please indicate the category of medical waste generator that best describes your facility.
 Large Quantity Generator with NO Onsite Treatment – This facility generates 200 pounds or more of medical/biohazardous
waste in any month of a 12-month period and medical waste is NOT treated onsite.
 Large Quantity Generator with Onsite Treatment – This facility is a LQG and medical/biohazardous waste is treated at this
facility
 Small Quantity Generator with Onsite Treatment – This facility generates less than 200 pounds of medical waste per month
in every 12-month period and medical/biohazardous waste is treated at this facility
 Common Storage Facility – This office building/complex/facility operates an area designated for the storage of
medical/biohazardous waste. This area is shared by multiple independently operated SQGs. The medical waste is transported
offsite by a registered medical waste hauler.
(Provide a list of generators that this Common Storage Facility serves. Add an additional sheet for more generators.)
generators served: _________
GENERATOR NAME
ADDRESS
Number of
PHONE NUMBER
Medical Waste Generator Registration Form
Page 1 of 3/ Sept 2016
III. TYPES OF MEDICAL/BIOHAZARDOUS WASTES GENERATED
Please indicate the type(s) of medical waste generated by this facility. Check all that apply.
 Fluid Blood Products (This includes dressings, containers or equipment containing fluid blood, fluid blood products,
or blood from animals known to be infected with diseases which are highly communicable to humans.)
 Laboratory Wastes (Specimen or biologic cultures, stocks of infectious agents, live and attenuated vaccines and
culture mediums, test tubes, vacuum tubes)
 Sharps (syringes, needles, blades, broken glass)
 Contaminated Animals (Animal carcasses body parts, bedding materials)
 Surgical Specimens (Human or animal parts or tissues removed surgically or by autopsy)
 Isolation Wastes (Wastes contaminated with excretion, exudates or from animals infected and isolated due to the
highly communicable diseases listed by the Centers for Disease Control)
 Trace Chemotherapeutic Wastes (Gloves, gowns, towels and I.V. solutions bags and empty tubings, etc.
contaminated with trace amounts of chemotherapeutic agents)
 Pharmaceutical Wastes (Outdated, unused California-only regulated pharmaceuticals)
 Other (Please specify.) ________________________________________________________________________
IV. QUANTITY OF MEDICAL/BIOHAZARDOUS WASTES GENERATED:
This facility generates this amount of regulated medical waste per month: _____________ lbs.
V. OUR WASTE IS:
 Picked up by a registered transporter; name and address: ________________________________________________

Refer to California Dept. of Public Health website for a list of authorized haulers:
http://www.cdph.ca.gov/certlic/medicalwaste/Pages/Transporters.aspx
 Mailed via Mail-Back System; name: _________________________________________________________________

Refer to California Dept. of Public Health website for mail back information:
http://www.cdph.ca.gov/certlic/medicalwaste/Pages/MailBack.aspx
 Treated onsite by autoclave _____________________ or by alternative treatment method ______________________
VI. NAME AND ADDRESS OF TREATMENT/DISPOSAL FACILITY:
If medical waste is disposed of or treated offsite, provide the following information:
Type of waste(s) (See Section III): _____________________________________________________________________
1. Name and address of registered Hazardous/Medical Waste Hauler:
_______________________________________________________________________________________
_______________________________________________________________________________________
2.
Name and address of Treatment/Disposal Facility:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
MW Generator Registration Form
Page 2 of 3/ Sept 2016
VII. MEDICAL WASTE MANAGEMENT PLAN
All generators required to register must have on file with the enforcement agency a current Medical Waste Management
Plan. The Medical Waste Management Plan shall include an Emergency Action Plan, which delineates the procedures for
properly handling on-site spills and releases of medical waste (H&SC §117943). The Emergency Action Plan should
address surface cleanup, protective clothing and equipment to be used, and disinfecting procedures. The Medical Waste
Management Plan must be updated as facility operations or personnel information changes occur. Please indicate the
status of your Medical Waste Management Plan:
___
A review of the Medical Waste Management Plan previously submitted to Alameda County DEH was
conducted and it was determined that a plan update is not required.
___
The Medical Waste Management Plan has been updated and is attached.
___
An approved Medical Waste Management Plan will be submitted to the Alameda County DEH with the
Certificate of Return to Compliance from the last onsite inspection.
VIII. CERTIFICATION
I declare under penalty of law that to the best of my knowledge, the statements made herein are correct and true.
Authorized Representative:
Print Name:
________________________________Title:___________________
Signature:
________________________________
Date: _____________________
The fee page is available on our website at http://acgov.org/aceh/solid/medical_waste_management.htm. Make the check
payable to Alameda County Department of Environmental Health. For other forms of payment, please refer to our website at
http://acgov.org/aceh/billing/index.htm.
Mail the application and fee to:
Alameda County Department of Environmental Health
1131 Harbor Bay Parkway
Alameda, CA 94502
FOR OFFICIAL USE ONLY
FA# __________________ PR#__________________
PAYMENT MADE:
AMOUNT: _______
DATE PAID: __________
APPROVED BY: __________________ DATE APPROVED: _______________
MW Generator Registration Form
Page 3 of 3/ Sept 2016